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APPLICATION FOR SENIOR CITIZEN
, PROPERTY TAX BENEFITS
` ; i Sbte Fortn d370B (R9l 408)
� �., P(escnbad hy Uie DeoaRment ol Local Govemmem Finance
IMotmatiom m�taineC in this tlowment is CONFIDENTIAL pursuant to IC 6-1.7-72-9 antl IC G1.1-35-9.
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INSTRUC710NS'
COUNTY TOWNSHIP I YEAR
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To 6e filed in persari or by mail with fhe CountyAutlita o/lhe counly where Ihe properfy is locafed.
Filiry Dates: fJ ReelProperty: Dunng fhe tweNe (72) months before Decem6er3f o7the year the deductionQ�bte�f�e�fl ,�
2) Mo6ile Homes assessed ulMer IC 6-7.1-7 or manWactured homes nof assessed as real property`�DUnnQ�twaNe� monU�s
belore March 37 olthe year the detluc6on is lo be eHective. �T Y AUD
�tOR
See reverse side fw addifiona/ insWdions andVUalifiwtions.
7ype of 6enefif raQUasted oesa tlieck a� Mat appyj
Over 65 Deduction from Assessed Valuation Over 65 Cirwit Breaker Credit
Name af a0 1 ( caHrsU Gvyv� U�
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Ls a�pGmM the e al or epuitaWe owneR il what is his/ner exad share or i-ferest9 I( owned wiV: mmaone ot�ar than 50ousa,
I:CImIB W1�M1 W:AT
❑ Yes ❑ No
if name on rewd is di@erant Nan thal of ao�ca�t indicata beiaw
Neme af contraG sellar (apWicant must Aaw been Guying on cmVact a! bas! one (1J yca�
Pddress of contrad sallar (number antl sbeel, cM• slato, eM ZIP wdo) Is ihe o�PeM �n duestion:
Real propery � Mobile home (1C 6-1-7-7)
Taxing distncl Key num6eN Legal da n0tion�O 1_ o^; i i%j�ecad ourt��r Page r.umcer
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is me orooeM used xnc occuded o�ma�N ror As�ssed valua of ina omperty as of Marcn ;, curreni year (may nof exceed>182.a30
hisRiar residenwT 7or O�er 65 dMUdirn, w S 160.0001or tho Ove� 65 Circuit &eaker Gedi:)
❑ Yes ❑ No
VJas the a0M��165 yean of aga w more on Oacember 31 of lne year Aooticant'S Cate o( drth (mm:F., day, yoa� If flec by a surviving. cn.ramed soouse.
odar to tha artem yeaR wFat was tne spouse's age at the tima
� YES � NO �� � (� — �� of deair.?
Adjusted gross income of appliwnt, spouse, and any � Source of Income � Amount of Intome
individuals sharing ownership (For Over 65 deduction, income I I S I
may not exceed 525,000; /or the Over 65 Circuit H2aker Credit,
income may not exceed 530,000 /or individuals, or 540, 000 for �
�� �-
Mave you filed for any other deductior.s? If Yes. x�hat aeductiors7
Yes � No /—/ J ,
Mave you fJed tw decuctions in any dher counry? If �s. wnat courry?
� Yes � No
IlWe certify under penalty of perjury that the above and foregoing information is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 7. 20
Signatcre ol a r.t ACEress of aoolimr.i (r.umber ^ntl sbeet, uy. sam. and code�
�_ � �j,�- 3os
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Sipnat � d ��odzed reoresenta � Mdress of authorize2 r=oresentaliva �nvmDC�a . sbco(. ciry, slate, antl Z1P code)